Anaesthetics & ICU Evidence Rundown — October 2026

ANAESTHETICS & INTENSIVE CARE MEDICINE

Anaesthetics & ICU Evidence Rundown

Issue 9 · October 2026 · UK Edition

Jake Turner — Senior Registrar in Emergency Medicine, ST6 — Curated with the assistance of AI (Perplexity). All content editorially reviewed.

Full archive and PDF downloads at emevidence.org

Lead: GLIMPSE (Anaesthesia, UK national prospective cohort, n=47,039): 1 in 35 patients under anaesthetic care were taking a GLP-1 receptor agonist, and pulmonary aspiration or regurgitation occurred in 1 in 71 of them versus 0.12% of others (OR 11.39). CHANGE THIS MONTH: GLP-1 RA patients — plan for aspiration risk, including at emergence • drug allergy labels (29% of patients in 21 NHS hospitals) linked to more complications — de-label where possible • MHRA NatPSA/2026/005 on hoists and slings • new AoA/BADS/APAGBI day surgery consensus.

BOTTOM LINE UP FRONT — OCTOBER 2026

ACT ON THIS NOW

CHANGE THIS MONTH GLIMPSE (n=47,039, 119 UK sites): aspiration/regurgitation 1.41% on GLP-1 RAs vs 0.12% without; most events at emergence. Perioperative management was highly variable.

CHANGE THIS MONTH SAPPHIRE (BJA, 21 NHS hospitals, n=13,646): drug allergy labels in 29%; complications 25% vs 20% (OR 1.21). Refer for de-labelling.

SAFETY MHRA NatPSA/2026/005: patient hoists and slings — deaths and serious harm from falls; check compatibility, pre-use checks and training in theatres and ICU.

CHANGE THIS MONTH Preoperative anaemia, Wales (n=46,614): 31% anaemic; 52% of these iron deficient; mortality aOR 1.69.

KNOW FOR NEXT TIME

INFORMING PRESSURE (JAMA, UK PCCS Study Group PICU RCT, n=1,900): permissive MAP target cut vasoactive dose 37.5% with no difference in the primary outcome.

INFORMING Intraoperative BP targeting (Bayesian MA, 15 RCTs): mortality OR 1.00; AKI OR 0.87 (CI crosses 1).

INFORMING Peripheral perfusion-guided resuscitation (7 RCTs, n=2,408): 28-day mortality RR 0.87 (0.76–1.01).

PAEDS Neonatal/infant airway (ESAIC/BJA): VL first choice — but a Japanese registry found VL linked to lower real-world first-attempt success (aRR 0.89).

This month's lead comes from UK trainees: the GLIMPSE collaborative recruited more than 47,000 patients across 119 sites to answer a question every anaesthetist now faces several times a week — what does a GLP-1 receptor agonist mean for aspiration risk? The answer is sobering, and a US paediatric gastric ultrasound study adds weight to it. Two more large UK cohorts, on drug allergy labels and preoperative anaemia, show how much perioperative harm sits in problems we can fix before the day of surgery. In critical care, the PRESSURE trial from the UK Paediatric Critical Care Society Study Group and two meta-analyses on blood pressure and perfusion targets all point the same way: less may be enough.

WHAT'S INSIDE

• Lead: GLIMPSE — GLP-1 receptor agonists and aspiration (Anaesthesia, UK)
• SAPPHIRE: drug allergy labels and postoperative complications (BJA, UK)
• Preoperative anaemia and iron deficiency in Wales (BJA, UK)
• PRESSURE: permissive MAP targets in PICU (JAMA, UK PCCS Study Group RCT)
• Intraoperative blood pressure targeting — Bayesian MA (Anesthesiology)
• Peripheral perfusion-guided resuscitation — MA (Crit Care Med)
• TRAIN secondary analysis: transfusion thresholds in TBI (JAMA Netw Open)
• Ketamine for analgosedation in ventilated adults — RCT (Crit Care Med)
• ED-to-ICU transfer delay and mortality (J Emerg Med)
• Corticosteroids in cardiogenic shock — MA (JICS, UK authors)
• UK: AoA/BADS/APAGBI day surgery consensus; RCoA State of the Nation; MHRA alerts
• Airway & Regional: neonatal and infant airway guideline; J-PEDIA VL and SAD studies; IV lidocaine in spine surgery; phenol PENG block for non-operative hip fracture
• Perioperative & Obstetric: GLP-1 RAs in adolescents; dexamethasone vs ondansetron after caesarean; remifentanil PCA vs epidural
• Quick Hits: X-COPD (ECCO2R), PRiVENT weaning programme, indirect calorimetry-guided feeding

• Core Revision: Pulmonary aspiration — risk, fasting, gastric ultrasound (Final FRCA)

CHANGE TONIGHT CHANGE THIS MONTH SAFETY ALERT GUIDELINE INFORMING PRACTICE ICU AIRWAY

REGIONAL

PERIOPERATIVE

OBSTETRIC

UK

FINAL FRCA

Contents: 1. Key Anaesthetics & ICU Articles — 2. Guidelines & UK Updates — 3. Airway & Regional — 4. Perioperative & Patient Safety — 5. FOAMed & Critical Appraisal — 6. Quick Hits — Core Revision — 7. Action Points — Trials to Watch

1 — KEY ANAESTHETICS & ICU ARTICLES

CHANGE THIS MONTH PERIOPERATIVE UK FINAL FRCA

Lead: GLIMPSE — 1 in 35 Patients Under Anaesthetic Care Take a GLP-1 Receptor Agonist, and 1 in 71 of Them Aspirated or Regurgitated

Potter TE, Cronin JN, Kua J, et al.; GLIMPSE Resident Research Networks and Collaborators. Peri-operative glucagon-like peptide-1 receptor agonist use and outcomes: a national prospective multicentre cohort study. Anaesthesia. 2026 (epub 16 September). doi:10.1111/anae.70380. PMID: 42748560.

Design: National prospective multicentre cohort of adults having elective or emergency procedures under anaesthetic care at 119 UK sites, delivered through trainee research networks. Patients were screened for GLP-1 RA use in the 3 months before the procedure. Primary outcome: proportion receiving GLP-1 RAs; secondary outcomes included perioperative management and the incidence of pulmonary aspiration and/or regurgitation.

Key results: 1,348 of 47,039 patients (2.9%, about 1 in 35) were taking GLP-1 RAs. Management of drug cessation, anaesthesia and airway technique was variable. Pulmonary aspiration and/or regurgitation occurred in 19/1,348 (1.41%, 95% CI 0.85–2.19%) on GLP-1 RAs vs 57/45,691 (0.12%, 95% CI 0.09–0.16%) not on them: OR 11.39 (95% CI 6.47–20.05), p<0.001. Among GLP-1 RA patients, events occurred most often during emergence.

• 47,039 PATIENTS, 119 UK SITES
• 2.9% TAKING GLP-1 RAS (1 IN 35)
• 1.41% vs 0.12% ASPIRATION/REGURGITATION, GLP-1 RA VS NONE
• OR 11.39 95% CI 6.47–20.05

Critical appraisal: This is a large, prospective national dataset and is directly UK-generalisable, with a well-defined exposure window. The abstract reports no adjusted estimate: GLP-1 RA users differ systematically (obesity, diabetes, possibly gastroparesis and more emergency or endoscopic procedures), so part of the excess risk may reflect these factors rather than the drug alone. A composite of aspiration and regurgitation will include clinically trivial regurgitation alongside true aspiration, and the absolute numbers are small (19 events). Because airway management was not randomised, the study cannot tell us which mitigation strategy works. The signal at emergence is important and easy to overlook if attention is focused only on induction.

UK practice: Ask about GLP-1 RA use (including privately obtained tirzepatide or semaglutide for weight loss) at every pre-assessment and on the day. Follow current UK multi-society and CPOC guidance on perioperative GLP-1 RA management; where residual gastric content is a concern, consider gastric ultrasound, liquid diet before surgery, a protected airway, and a planned, controlled emergence with the patient awake and positioned before extubation.

CHANGE THIS MONTH PERIOPERATIVE UK

SAPPHIRE: Drug Allergy Labels in 29% of Patients Across 21 NHS Hospitals — and More Postoperative Complications

Savic LC, Dias P, Vairale J, et al.; SAPPHIRE study investigators. Drug allergy labels and complications after surgery: a prospective multicentre cohort study. Br J Anaesth. 2026 (epub 10 September). doi:10.1016/j.bja.2026.07.035. PMID: 42722596. ISRCTN15775657.

Design: Prospective observational study in 21 NHS hospitals of adults having common procedures (hip or knee replacement, long-bone fixation, colorectal resection, TURP/TURBT, caesarean delivery, hysterectomy). Primary outcome: a composite of 30-day complications (infections, anastomotic leak, ARDS, MI, bleeding, PE, stroke, antimicrobial side-effects and death).

Key results: 3,924 of 13,646 (29%) carried at least one drug allergy label. Labelled patients had more complications (989/3,924 [25%] vs 1,926/9,722 [20%]; OR 1.21, 95% CI 1.10–1.34), more surgical site infection (9% vs 8%; OR 1.19) and any postoperative infection (19% vs 15%; OR 1.24), and more allergic drug reactions (OR 3.00), but no increase in mortality.

• 29% CARRY A DRUG ALLERGY LABEL
• 25% vs 20% 30-DAY COMPLICATIONS, LABELLED VS NOT
• 19% vs 15% ANY POSTOPERATIVE INFECTION

Critical appraisal: Large, UK, prospective and registered, with clinically meaningful outcomes. The association cannot show that the label itself causes harm; the abstract does not report how antibiotic choice or baseline differences between groups contributed. The abstract does not present adjusted estimates. Absolute differences are modest (about 5 percentage points for the composite), but at population scale this is a large burden of avoidable harm.

UK practice: Take a structured allergy history at pre-assessment, record the actual reaction, and refer low-risk penicillin labels for de-labelling through local pathways, in line with the BSACI penicillin allergy guidance, ideally well before elective surgery.

CHANGE THIS MONTH PERIOPERATIVE UK

Preoperative Anaemia in Wales: 31% of Major Elective Surgical Patients, Half With Iron Deficiency, and Higher Mortality at Every Time Point

Evans CR, Rollings J, Capel R, Withers K, Ditcham S. Preoperative anaemia and iron deficiency in Wales: a national retrospective cohort study of postsurgical outcomes after major elective surgery. Br J Anaesth. 2026 (epub 28 September). doi:10.1016/j.bja.2026.08.038. PMID: 42805893.

National retrospective cohort (January 2018 to May 2025) of 46,614 adults having major elective GI, cardiac, urological, gynaecological or orthopaedic surgery during roll-out of the NHS Wales Preoperative Anaemia Pathway (anaemia Hb <130 g/L; iron deficiency ferritin <30 µg/L or TSAT <20%). 31% were anaemic and 52% of those were iron deficient. Anaemia was independently associated with longer stay (adjusted rate ratio 1.17), 30-day readmission (aOR 1.18) and higher mortality at all time points (aOR 1.69, 95% CI 1.54–1.85); iron deficiency and anaemia with inflammation carried particularly poor outcomes.

Appraisal: Observational, so anaemia may be a marker of illness severity rather than a cause; the study does not show that correcting it improves outcomes (PREVENTT found no benefit from preoperative IV iron on its primary outcome). A single uniform threshold of 130 g/L for both sexes is a pragmatic pathway choice.

UK practice: Screen for anaemia early enough in the elective pathway to investigate and treat the cause; iron studies should be routine when Hb is low. A national pathway like Wales's makes this deliverable.

INFORMING PRACTICE ICU UK NETWORK

PRESSURE: A Permissive MAP Target in Ventilated, Hypotensive Children Cut Vasoactive Exposure by 37.5% With No Difference in the Primary Outcome

Inwald DP, Laing E, Broomhall JM, et al.; PRESSURE Trial Investigators on behalf of the UK Paediatric Critical Care Society Study Group. Permissive blood pressure targets in pediatric critical care: the PRESSURE randomized clinical trial. JAMA. 2026 (epub 28 September). doi:10.1001/jama.2026.19747. PMID: 42806496. ISRCTN20609635.

Design: Pragmatic, unblinded RCT in 23 PICUs in 3 countries (November 2021 to May 2026). Children receiving invasive ventilation and vasoactive drugs for hypotension were randomised to a permissive MAP target (>5th centile for age; n=957) or usual care with MAP target set by the attending clinician (n=943). Primary outcome: a composite of mortality and duration of invasive ventilation at 30 days.

Key results: 1,814 analysed (median age 4 years). Median MAP on vasoactives was 58 vs 61 mmHg; median noradrenaline-equivalent total dose was 37.5% lower in the permissive group. No difference in the primary outcome (probabilistic index 0.52, 95% CI 0.49–0.54; p=0.23). Six of seven secondary outcomes were similar; PICU stay in survivors was slightly shorter with the permissive target (159 vs 166 hours). Kidney replacement therapy and adverse events did not differ.

• 1,900 CHILDREN RANDOMISED, 23 PICUS
• −37.5% VASOACTIVE DOSE WITH PERMISSIVE TARGET
• 58 vs 61 MEDIAN MAP (MMHG)
• PI 0.52 PRIMARY OUTCOME (95% CI 0.49–0.54)

Critical appraisal: A large trial run with the UK Paediatric Critical Care Society Study Group, with a pragmatic design that reflects real PICU practice. The separation in achieved MAP was only about 3 mmHg, which limits how far the result can be extrapolated to very different targets; the main effect was on drug exposure. Unblinding is unavoidable but could influence ventilation decisions within the composite outcome. The direction is consistent with adult data suggesting lower targets reduce vasopressor exposure without clear harm.

UK practice: For ventilated hypotensive children, a MAP above the 5th centile for age is a defensible target that reduces vasoactive exposure. Anaesthetists stabilising children for transfer should discuss targets with the PICU or retrieval team.

INFORMING PRACTICE PERIOPERATIVE FINAL FRCA

Protocolised Intraoperative Blood Pressure Targets Show No Consistent Benefit Over Usual Care — Bayesian Meta-analysis of 15 RCTs

Ripollés-Melchor J, Espinosa ÁV, Monge-García I, et al. Intraoperative blood pressure targeting in noncardiac surgery: a Bayesian random-effects meta-analysis of randomized trials. Anesthesiology. 2026 (epub 28 September). doi:10.1097/ALN.0000000000006395. PMID: 42803396.

Fifteen RCTs in major noncardiac surgery comparing protocolised arterial pressure targeting with usual care or lower-pressure approaches (prespecified Bayesian primary analysis). Mortality (13 trials): frequentist OR 1.00 (95% CI 0.83–1.21), Bayesian median OR 1.00 (95% CrI 0.73–1.38). AKI (14 trials): OR 0.87 (95% CI 0.73–1.03), Bayesian OR 0.88 (CrI 0.70–1.05), with moderate heterogeneity and sensitivity to removing individual trials. MINS (8 trials): OR 1.04 (95% CI 0.93–1.15).

• OR 1.00 MORTALITY (13 RCTS)
• OR 0.87 AKI (0.73–1.03)
• OR 1.04 MINS (0.93–1.15)

Critical appraisal: "Usual care" has improved over time, so newer trials compare against an already-active control; heterogeneity in targets (absolute vs individualised) and populations limits a single pooled answer. The AKI signal is the only plausible benefit and is fragile. Avoiding prolonged profound hypotension remains sensible; protocolised targets beyond that are not yet shown to add value.

INFORMING PRACTICE ICU

Peripheral Perfusion-Guided Resuscitation in Septic Shock: Mortality RR 0.87, Just Missing Significance — Bayesian Probability of Benefit 97.2%

Mendes H, Silva Correia JV, Moreira Salles MM, Kattan E, Hernández G, Melo RH. Mortality effect of peripheral perfusion-guided resuscitation in vasodilatory shock: a systematic review and dual frequentist-Bayesian meta-analysis of randomized trials. Crit Care Med. 2026 (epub 11 September). doi:10.1097/CCM.0000000000007364. PMID: 42725818.

Seven RCTs (n=2,408), all in septic shock, comparing peripheral perfusion-guided resuscitation with standard or lactate-guided care. 28-day mortality RR 0.87 (95% CI 0.76–1.01; p=0.06; I²=0%; moderate certainty). Bayesian posterior probability RR <1: 97.2%, consistent across priors. The two largest, lowest-risk trials were individually non-significant.

Appraisal: The result rests heavily on two large trials; the size of any benefit remains uncertain. The intervention is cheap and bedside, which is why a probable modest benefit matters.

UK practice: Capillary refill time is a reasonable, free resuscitation target alongside lactate in early septic shock; it does not replace clinical judgement about fluid tolerance.

INFORMING PRACTICE ICU FINAL FRCA

TRAIN Secondary Analysis: Liberal Transfusion (Hb <9 g/dL) Associated With Fewer Unfavourable Outcomes in TBI — Fragility Index 1

Zernini IS, Faso C, Rynkowski CB, et al.; TRAIN Study Trial Group. Restrictive vs liberal transfusion strategy in traumatic brain injury: a secondary analysis of the TRAIN trial. JAMA Netw Open. 2026;9(9):e2632555. doi:10.1001/jamanetworkopen.2026.32555. PMID: 42709438.

Preplanned secondary analysis of the TBI subgroup of TRAIN (72 ICUs, 22 countries, 2017–2022): 475 patients analysed, liberal (transfuse Hb <9 g/dL) vs restrictive (<7 g/dL). Unfavourable neurological outcome (GOS-E 1–5) at 180 days: 58.5% vs 67.4% (RR 0.86, 95% CI 0.75–1.00; p=0.047; fragility index 1). 28-day mortality 17.5% vs 20.9% (RR 0.84, 95% CI 0.58–1.21). No difference in serious adverse events. Adjusted OR for unfavourable outcome 0.60 (95% CI 0.38–0.94).

• 475 TBI PATIENTS ANALYSED
• 58.5% vs 67.4% UNFAVOURABLE OUTCOME, LIBERAL VS RESTRICTIVE
• FI = 1 FRAGILITY INDEX

Critical appraisal: A preplanned subgroup of a randomised trial, so randomisation is preserved, but subgroup analyses carry less precision than a dedicated trial, and with a fragility index of 1 a single changed event would remove statistical significance. It is concordant with HEMOTION's direction but should be read as hypothesis-strengthening.

INFORMING PRACTICE ICU

Low-Dose Ketamine Infusion for Analgosedation in Ventilated Adults: Modest Opioid Sparing, No Change in Delirium

Casamento AJ, Ghosh AN, Said S, et al. Ketamine for analgosedation in mechanically ventilated adults: a double-blind randomized trial. Crit Care Med. 2026 (epub 7 September). doi:10.1097/CCM.0000000000007341. PMID: 42704275.

Double-blind placebo-controlled RCT in two Melbourne ICUs (2022–2024): 120 ventilated adults on opioid infusions (excluding cardiac surgery) received ketamine 0.15 mg/kg/h (n=59) or placebo (n=61). Median hourly opioid dose (fentanyl equivalents) 64 vs 77 µg/h; median difference −13.0 µg/h (95% CrI −26.6 to 2.4); probability of benefit 95.1%. No differences in delirium or significant adverse events.

Appraisal: Small and two-centre, with opioid dose (a process measure) as the primary outcome; the credible interval includes no effect. Encouraging for safety, but it does not establish patient-centred benefit.

CHANGE THIS MONTH ICU

ED-to-ICU Transfer Delay Over 4 Hours Associated With Doubled In-Hospital Mortality — Most Delay Occurs After ICU Acceptance

Kabahasanoglu K, Bektas MH, Ozturk Ormeci G, Beyoglu R. Emergency department-to-intensive care unit transfer delay and mortality in critically ill adults: a 5-year retrospective cohort study. J Emerg Med. 2026;89:140–152. doi:10.1016/j.jemermed.2026.08.013.

Single-centre Turkish cohort of 650 adults transferred from ED to two level-3 ICUs (2020–2024). 54.0% waited over 4 hours; median total time 4.3 hours, of which 3.0 hours came after ICU acceptance. Delay over 4 hours: in-hospital mortality aRR 2.01 (95% CI 1.46–2.76), adjusted 27.5% vs 13.8%; ICU mortality aRR 1.70. Each post-acceptance boarding hour: aOR 1.14 (95% CI 1.06–1.24).

ICU angle: Retrospective and single-centre with likely residual confounding, but the finding that most delay follows acceptance points to post-acceptance boarding as an actionable, system-level target that involves ICU teams as much as the ED. Also covered for ED readers in EM Evidence Rundown Issue 32.

UK practice: Once a patient is accepted, the ICU team owns their care plan wherever they are. Track decision-to-bed times as an ICU quality metric, consistent with GPICS standards on timely admission.

INFORMING PRACTICE ICU UK AUTHORS

Corticosteroids in Cardiogenic Shock: Used in 7–29% of Patients, and Insufficient Evidence on Mortality

Zwengunde C, White L, Campbell D, et al. Corticosteroid therapy in cardiogenic shock: a systematic review and meta-analysis. J Intensive Care Soc. 2026 (epub 22 September). doi:10.1177/17511437261483562. PMID: 42787332.

Pre-registered review: eight studies (four RCTs, four observational), with three observational studies of clearly defined cardiogenic shock in the primary analysis. Observational data suggested 7–29% of patients received systemic corticosteroids. No evidence of an effect on acute mortality in unadjusted analysis (RR 1.05, 95% CI 0.98–1.13; very low certainty); weak, very low-certainty evidence of more hyperglycaemia and hospital-acquired infection. The authors conclude the evidence is insufficient to determine the effect.

UK practice: There is no evidence base for routine steroids in cardiogenic shock; reserve them for specific indications such as known adrenal insufficiency or concurrent septic shock.

2 — GUIDELINES & UK UPDATES

GUIDELINE UK PERIOPERATIVE

Peri-operative Management of Day Surgery: Consensus Statement From the Association of Anaesthetists, BADS and APAGBI

Bailey CR, Bunting D, Hudman L, et al. Peri-operative management of patients having day surgery: a consensus statement from the Association of Anaesthetists, British Association for Day Surgery and the Association of Paediatric Anaesthetists of Great Britain and Ireland. Anaesthesia. 2026 (epub 15 September). doi:10.1111/anae.70408. PMID: 42743690.

Day surgery rates in the UK now exceed 85%, yet vary widely across the UK. Following a targeted literature review and a two-round modified Delphi, the statement makes recommendations on patient selection, pre-assessment and optimisation; comorbidities including frailty, obesity and obstructive sleep apnoea; urgent and emergency day-case surgery; logistics; anaesthetic technique; and discharge, for adults and children.

Appraisal: Consensus rather than primary evidence, but from the relevant UK bodies, so it will become the reference standard for day surgery services and pre-assessment pathways.

UK practice: Day surgery leads should compare local selection criteria (especially for obesity, OSA and frailty) and discharge processes against the new statement.

INFORMING PRACTICE UK

RCoA UK State of the Nation 2026: A Shortfall of Around 2,250 Anaesthetists

Royal College of Anaesthetists. UK State of the Nation report 2026, as summarised by the TRFT Health Weekly Digest, 11 September 2026. trfthealthweeklydigest.wordpress.com.

The report estimates a UK-wide shortfall of around 2,250 anaesthetists (16% below need), with up to 1.5 million operations and procedures unable to take place each year as a result. 53% of respondents reported that women in labour were sometimes delayed in getting pain relief because of a lack of anaesthetists. There were 6,770 applications for 539 core anaesthetic training places in the previous year.

SAFETY ALERT UK

MHRA September 2026: Hoists and Slings NatPSA, Fluenz Syncope, Wireless CTG Interference, Levetiracetam Leaflet

MHRA Safety Roundup: September 2026 (29 September). gov.uk/drug-device-alerts/mhra-safety-roundup-september-2026. MHRA EL(26)A/40 (1 October). gov.uk alert EL(26)A/40.

NatPSA/2026/005/MHRA: deaths and serious harm from falls from patient hoists and slings (an average of two deaths per year since 2015), linked to incompatible hoist–sling combinations, damaged or incorrectly seated loops, missed pre-use checks, overdue maintenance and training gaps. This applies wherever hoists are used, including ICU and theatres. DSI/2026/012: wireless CTG monitors on the same RF channel can show another patient's fetal heart rate; verify traces against maternal pulse and keep a wired backup on labour ward. Fluenz: increased risk of fainting immediately after nasal administration. Levetiracetam Neuraxpharm sachets (EL(26)A/40): Class 4 defect notification (published 1 October): the patient leaflet does not contain all the reference product information; the quality of the granules is not affected.

Action: Confirm your ICU and theatres have acted on the hoist and sling NatPSA, including compatibility checks and staff competence.

3 — AIRWAY & REGIONAL

CHANGE THIS MONTH AIRWAY FINAL FRCA

Neonatal and Infant Airway Management: The ESAIC/BJA Guideline Summarised — and a Real-World Warning About Videolaryngoscopy

(1) Long B, Gottlieb M. Guideline update: neonatal and infant airway management. Am J Emerg Med. 2026;109:259–262. doi:10.1016/j.ajem.2026.07.056 (summary of the 2024 ESAIC/BJA joint guideline). (2) Ukiya T, Watanabe F, Okuyama M, et al. Videolaryngoscopy and first-attempt tracheal intubation success in neonates and infants: J-PEDIA registry. Br J Anaesth. 2026 (epub 23 September). doi:10.1016/j.bja.2026.07.070. PMID: 42778452.

Guideline (children under 1 year): predict difficulty from history and examination; ensure adequate anaesthesia (for example etomidate or ketamine) with neuromuscular blockade where maintaining spontaneous breathing is not necessary; videolaryngoscopy with an age-adapted standard blade (Macintosh or Miller) as first choice; apnoeic oxygenation during tracheal intubation of neonates (1B); cuffed or uncuffed tubes both acceptable (cuffed in children >3 kg); supraglottic airway for rescue oxygenation (1B); limit attempts and change technique, operator or both after each failure; stylet with hyperangulated blades or anterior airways; capnography to confirm placement. Atropine was not associated with less bradycardia.

J-PEDIA (3,250 encounters, Japan, 2022–2025): after propensity weighting, VL for the first attempt was associated with lower first-attempt success than direct laryngoscopy (aRR 0.89, 95% CI 0.83–0.96) and more desaturation (aRR 2.18), despite better glottic views; respiratory adverse events were similar.

• 3,250 NEONATAL/INFANT ENCOUNTERS (J-PEDIA)
• aRR 0.89 FIRST-ATTEMPT SUCCESS, VL VS DL
• aRR 2.18 DESATURATION WITH VL

Critical appraisal: The registry finding is observational and VL may have been chosen for anticipated difficult airways or by less experienced operators, so confounding by indication is likely; the authors frame it as an efficacy–effectiveness gap. Read together, the two papers say VL is the right default, but only with structured training, standard-geometry blades and attention to apnoea time.

UK practice: Make standard-geometry neonatal and infant VL blades available wherever infants are anaesthetised, train with them routinely, and use apnoeic oxygenation for neonatal intubation.

INFORMING PRACTICE AIRWAY

Supraglottic Airways vs Tracheal Intubation in Children With Airway Hyperresponsiveness: Fewer Respiratory Adverse Events

Uchinami Y, Soejima T, Nishida S, et al. Association between supraglottic airway device use and respiratory adverse events during airway management in children with airway hyperresponsiveness: a report from the J-PEDIA registry. Br J Anaesth. 2026 (epub 29 September). doi:10.1016/j.bja.2026.07.046. PMID: 42810867.

4,878 encounters in children with active or recent URTI, asthma exacerbation or household smoke exposure at 12 Japanese centres: SAD placement (38.4%) vs tracheal intubation was associated with fewer respiratory adverse events (aRR 0.41, 95% CI 0.19–0.62), fewer airway-related adverse events (aRR 0.32) and less severe desaturation (aRR 0.47). Retrospective, with likely residual confounding by procedure type.

INFORMING PRACTICE REGIONAL

IV Lidocaine in Spine Surgery: Meaningful Benefit After Fusion, Not After Decompression

Felippe VA, Bersot CDA, Gonzalez GL, et al. Procedure-specific effects of intravenous lidocaine in adult spine surgery: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med. 2026 (epub 3 September). doi:10.1136/rapm-2026-108266. PMID: 42692530.

Ten RCTs: pain at 24 hours MD −0.83 (95% CI −1.36 to −0.30; 9 trials, 655 patients; I²=89%; prediction interval −2.69 to 1.02) and opioid use −11.64 mg IV morphine equivalents. In a post hoc subgroup analysis, benefit exceeded the 1-point MCID after instrumented fusion or complex surgery (MD −1.23) but was minimal after decompression (MD −0.20). No effect on PONV or length of stay. High heterogeneity and a post hoc subgroup mean this is hypothesis-generating.

UK practice: If using IV lidocaine, follow the Association of Anaesthetists/RA-UK consensus on safe IV lidocaine infusion, including dosing by ideal body weight and monitoring.

INFORMING PRACTICE REGIONAL

Phenol PENG Block for Non-Operative Hip Fracture Management in Frail Patients: Pain Control in a Population With 62% 30-Day Mortality

Smits RJH, Lommerse MI, Wijnen HH, et al.; Dutch-PENG registry collaborators. Pericapsular nerve group block with phenol for non-operative hip fracture management in patients living with frailty. Anaesthesia. 2026 (epub 8 September). doi:10.1111/anae.70346. PMID: 42711957.

Prospective cohort at seven Dutch hospitals: 103 patients (mean age 87; 51% nursing home residents; 76% cognitively impaired) choosing non-operative management received ultrasound-guided PENG neurolysis with phenol 6% (mean 10 mL). At 1 week, 94% of responders reported acceptable pain at rest and 89% no or acceptable pain on washing and dressing; 45% could transfer bed to chair. No procedure-related adverse events. 30-day mortality 62%; median survival 9 days. Uncontrolled, and with high early mortality the denominators for later outcomes are small.

4 — PERIOPERATIVE & PATIENT SAFETY

INFORMING PRACTICE PERIOPERATIVE

GLP-1 RAs in Adolescents: 80% Had Solids on Gastric Ultrasound After a Median 13-Hour Fast

O'Brien EM, Gallop R, Washburn M, et al. Delayed gastric emptying in adolescent patients on GLP-1 receptor agonists with standard preoperative fasting guidelines: a prospective cohort study. Br J Anaesth. 2026 (epub 8 September). doi:10.1016/j.bja.2026.07.016. PMID: 42711215.

Single-centre US cohort of 67 adolescents (10–18 years): solids were seen on gastric ultrasound in 16/20 (80%) on GLP-1 RAs, 17/27 (63%) of an at-risk group not on GLP-1 RAs, and 1/20 (5%) of healthy controls, despite median fasting of 13 hours for solids. Small numbers, but it complements GLIMPSE (above) and supports gastric ultrasound where there is doubt.

INFORMING PRACTICE OBSTETRIC

Dexamethasone vs Ondansetron as First-Line Antiemetic After Caesarean: No Difference in Rescue Medications

Berger AA, Borrelli MC, Patrocinio M, et al. A double-blinded randomized trial comparing dexamethasone to ondansetron as the first-line antiemetic after cesarean delivery. Anesth Analg. 2026 (epub 10 September). doi:10.1213/ANE.0000000000008321. PMID: 42721472.

Double-blind RCT (95 of 100 completed): dexamethasone 8 mg vs ondansetron 4 mg after spinal anaesthesia with intrathecal morphine 150 µg and an ERAS protocol. Rescue medications for nausea, pain or pruritus in 24 hours: 0.40 vs 0.23 per patient (p=0.337); no differences in pain, nausea or pruritus scores. Small and probably underpowered; low baseline pain may have masked a dexamethasone analgesic effect.

INFORMING PRACTICE OBSTETRIC

Remifentanil PCA vs Labour Epidural in 52,118 Births: Fewer Operative Deliveries, More Postpartum Haemorrhage

Režonja K, Lučovnik M, Verdenik I, Mirković T, Pintarič TS. Labor and delivery outcomes with remifentanil PCA versus labor epidural analgesia among women with and without obesity. Int J Obstet Anesth. 2026;68:105275. doi:10.1016/j.ijoa.2026.105275. PMID: 42715889.

Slovenian population cohort (2015–2024), stratified by BMI <30 (n=46,448) and ≥30 (n=5,670). Remifentanil PCA was associated with lower risks of intrapartum caesarean and operative vaginal delivery in both strata, but higher risk of postpartum haemorrhage in both, and of transfusion and third- or fourth-degree tears in women with BMI <30; neonatal outcomes were otherwise comparable. Observational: women who choose or receive epidurals typically have longer, more complicated labours, so confounding by indication is substantial.

5 — FOAMED & CRITICAL APPRAISAL

CRITICAL APPRAISAL

Reading This Month's Papers: Composite Outcomes, Fragility and the Efficacy–Effectiveness Gap

Three appraisal lessons recur in this issue. Composite outcomes: GLIMPSE combines aspiration with regurgitation, and SAPPHIRE combines infections with MI, stroke and death; always check which components drive the result. Fragility: the TRAIN TBI result would lose significance with a single changed event (fragility index 1). Efficacy versus effectiveness: videolaryngoscopy improves glottic views in trials, yet a large real-world registry found lower first-attempt success, a reminder that a device's benefit depends on training, blade choice and the operator.

6 — QUICK HITS

ICU — X-COPD (ECCO2R for intubated AE-COPD). Stopped early for financial reasons after 18 of 192 planned patients; death or severe disability at day 60 0/8 vs 3/9 (p=0.21); invasive ventilation 7.1 vs 24.3 days (p=0.043). Far too small to change practice. Crit Care. 2026. PMID 42693471.

ICU — PRiVENT specialist-led weaning programme. Non-randomised, with claims-data controls (349 vs 1,768): successful weaning 58.3% vs 51.7%; adjusted primary OR 1.46 (95% CI 0.99–2.17; p=0.057), with significant results in propensity-matched and ICU-survivor exploratory analyses only. Crit Care. 2026. PMID 42823746.

Weaning centre — indirect calorimetry-guided feeding during prolonged weaning. Double-blind RCT at a rehabilitation hospital (n=211): successful weaning 58% vs 50% (p=0.33); 1-year mortality 48% vs 56% (p=0.29). No significant benefit. Crit Care. 2026. PMID 42791574.

CORE REVISION — ISSUE 9 — FINAL FRCA

Perioperative Pulmonary Aspiration: Risk, Fasting and Gastric Ultrasound

From GLP-1 receptor agonists to the full-stomach patient

Exam goal: Describe risk factors for aspiration, the rationale for fasting rules, how to assess gastric content with ultrasound, and the immediate management of suspected aspiration.

1. RISK FACTORS

2. GASTRIC ULTRASOUND (QUALITATIVE ANTRAL GRADING)

Quantitative assessment estimates gastric fluid volume from antral cross-sectional area; a volume of about 1.5 mL/kg or more is commonly used to indicate increased risk.

3. SUSPECTED ASPIRATION — IMMEDIATE MANAGEMENT

7 — ACTION POINTS

• GLP-1 RAs: Ask about use at pre-assessment and on the day; follow UK guidance; plan for aspiration risk at induction and emergence.
• Allergy labels: Record the actual reaction; refer low-risk penicillin labels for de-labelling before elective surgery.
• Anaemia: Screen and investigate iron status early in the elective pathway.
• Hoists and slings: Confirm ICU and theatre compliance with NatPSA/2026/005.
• Labour ward: Check wireless CTG channel separation and wired backup (DSI/2026/012).
• Day surgery: Review local selection and discharge criteria against the new AoA/BADS/APAGBI consensus.
• Infant airway: Standard-geometry VL blades available and practised; apnoeic oxygenation for neonatal intubation.
• ICU flow: Track decision-to-bed times for accepted ED patients.

TRIALS TO WATCH

RECENTLY REPORTED

PRESSURE UK PICU MAP target RCT, JAMA September 2026 (this issue).

RECRUITING / ONGOING

NEEDED

GLP-1 RA mitigation No randomised evidence yet on which perioperative strategy (drug withholding, liquid diet, gastric ultrasound, RSI) reduces aspiration.

Anaesthetics & ICU Evidence Rundown — Issue 9 — October 2026 Curated by Jake Turner, Senior Registrar in Emergency Medicine, ST6 | Curated with the assistance of AI (Perplexity). All content editorially reviewed. Feedback: Submit feedback | emevidence.org | Contact: emevidence999@gmail.com Educational evidence summaries only. Not a substitute for clinical judgement, local guidelines or the primary sources.